Office-based psychotherapy practice is a challenging and vexing task for psychiatrists. Psychotherapy has not yet found a firm footing as an accepted form of therapy by many patients. Psychiatrists offering psychotherapy as a treatment face many challenges that may be social, psychological, and ethical. The present review paper posits an overview of the various challenges that besiege office-based psychotherapy in private psychiatric practice. Issues right from the initiation and basic premise of describing psychotherapy and issues concerning its mechanism of action and efficacy along with individualization of therapy are discussed. The challenges of online psychotherapy and dealing with clients that refuse medical help along with the perils of eclectic psychotherapy are highlighted. Handling adolescents which poses many challenges is also discussed along with an emphasis on the sound termination of psychotherapy. The paper aims to sensitize the readers to the various challenges that office-based psychotherapy poses while providing an overview on the subject. Each of the challenges in this paper is subtopics in themselves and may warrant separate review papers in their own right.

Psychotherapy is a form of psychological therapy where a trained therapist enters into a professional relationship with the patient with the aim of either removing certain symptoms, reducing certain symptoms, and bringing about overall growth and development of the personality of the patient.[1] It is a treatment that employs various modalities that are specific and organized in their approach to treatment. Psychotherapeutic practice requires in-depth training to utilize a range of therapeutic interventions.[2] Office-based psychotherapy in an outpatient private psychiatry practice is not a regular feature in various psychiatric clinics. Usually, many clinics have psychologists and trained psychotherapists that carry out therapy. The psychiatrist plays a primary role in diagnosing and psychopharmacological management of various psychiatric disorders along with psychoeducation of the caregivers. There are many reasons why office-based psychotherapeutic practice serves as a challenge for psychiatrists in private practice. The following paper looks at various challenges that may deter psychiatrists from the use of office-based psychotherapy in India. This paper aims to serve as primer for psychiatrists to sensitize them to various challenges they may encounter while they maintain an office psychotherapy practice.

The Challenges for Office-Based Psychotherapy

Challenge 1 – The acceptance of psychotherapy as a valid psychiatric treatment

It has been the usual belief in India that doctors prescribe medications and that there is a pill for every ill. One of the biggest challenges faced by Indian psychiatry is the acceptance of psychotherapy as a valid psychiatric treatment. Most patients coming in for psychiatric treatment expect medication and some advice from their doctor but rarely would they want to come and speak about their problems and try and dissect out various factors or identify a root cause for the same. Time constraints, financial constraints, lack of readiness to speak or discuss, an inhibition to open up before a doctor, and primitive beliefs that just talking and counseling cannot cure leads to a lack of faith among patients in psychotherapy as a treatment.[3]

There is a firm thought that one cannot get anywhere by just speaking and hence it is essential that medications and injections provide a cure rather than the mundane exercise of ascertaining whether one's thoughts are rational or not as in therapy. Patients who come in for psychiatric treatment are very often breadwinners for their families and may not have the time to come in for regular sessions which serves as another deterrent for regular psychotherapy. In fact, psychiatrists overcome this challenge by having what we refer to as mini-sessions of therapy during each consultation where multiple psychotherapeutic perspectives and techniques are used and put forth before the patients in short packets of 15–20 min each during each consultation without using the term psychotherapy. This is then looked upon by the patient as sound advice and he may even follow it rigorously without realizing that it is indeed psychotherapy that is helping him or her.[4]

Challenge 2 – Explaining to patients how psychotherapy works and their ability to comprehend and understand the same

Psychotherapy works in various ways and this may involve thought and emotional replacement and change of perspectives that comes about as the sessions progress. Sadly, there is no clear neurobiological mechanism of action of psychotherapy and the process of thought or emotional change when explained to patients is often viewed with skepticism as many patients find it unlikely that just talking to a therapist help change the thought patterns and beliefs that they have held on to for many years. Unlike a medication where the neurochemical theory of its action holds true and we can explain how a drug acts, it is very difficult to define a theory of how psychotherapy acts as well as how much time it would take before the patient perceives a visible change. Sadly, we have no blood tests or investigations in psychiatry to explain quantitatively how changes shall come in and this is a hindrance when it comes to patients opting for psychotherapy as a treatment in psychiatric settings.[5]

This is indeed a grave challenge as many psychiatrists have been trained biologically and lack the psychodynamic rigor and psychotherapeutic mindedness needed for psychotherapy. This also stems from the fact that psychotherapy training is a rather meager part of their postgraduate training and psychotherapy does not hold the same charm for them as medication or electroconvulsive therapy. I also shudder to suppose that training of psychiatrists very often occurs in busy outpatient departments and inpatient wards which leave little time and room for them to practice their psychotherapeutic skills while they may have studied the theory of psychotherapy well. Furthermore, training in their postgraduate course very often occurs in government aided and municipal hospitals where the patients are more open to medical line of management and rarely maintain a follow-up when asked to come for psychotherapy. Even though they may be trained, psychiatrists rarely are supervised during psychotherapy, and this may also disillusion them for using psychotherapy actively in their practices. Busy private psychiatry practice also leaves little time for psychotherapy and hence very often this is a modality that is handed over to psychologists or therapists working with the psychiatrist. The time of one psychotherapy session in private practice is equal to seeing 4–5 follow-up cases, and this may thus serve as a deterrent to psychiatrists developing an active psychotherapy practice.[6]

Challenge 4 – The individualization of psychotherapy

Another challenge in psychotherapy practice is that one size never fits all. Psychotherapy practice requires the psychiatrist to develop a flexible approach where he may have to be an ardent listener in one session and a good speaker in the next. There are patients who are interactive and may talk and make the psychotherapy session a lively dialog while there are others who may just nod and expect all the work to be done by the therapist. The therapist may have keep probing and prodding to get information which may get cumbersome, and a disinterest in such patients may develop by the therapist. Some patients need a well-structured format of psychotherapy while others go with the flow as sessions take them. Some may have fixed ideas and goals of what they wish to achieve from psychotherapy while others have no aim or rationale in undergoing therapy itself. Thus, the busy psychiatrist shall have to deal with these challenges and individualize his approach in psychotherapy with each patient keeping in minds their personality, therapeutic needs, and basic psychiatric disorder.[7],[8]

Challenge 5 – Choosing a school of psychotherapy and the perils of eclecticism

Many psychiatrists often face confusion and disagreement over which school of psychotherapy works best and what is best suited to Indian patients. Many psychiatrists may specialize and undergo training in specific schools of psychotherapy such as cognitive behavior therapy or rational emotive behavior therapy, but these schools while being superficial may also not fit every patient who came for therapy. The psychiatrist needs to have a fair idea of schools of therapy such as transactional analysis, gestalt therapy, and existentialism. The psychiatrist should also have an understanding of psychodynamic case formulation which will not only help pave the way for effective psychotherapy but also help in goal setting and explaining the cause of symptoms to patients. While specializing in a specific school of therapy may be useful, it is an eclectic approach based on the intellectual capacity and psychological mindedness of patients that works best in Indian settings. This eclecticism may also be viewed sometimes by patients and relatives as the psychiatrist's inadequacy or lack of specialization in a particular form of therapy. Many patients like to know what therapy they are undergoing and eclectic is a word that may not appeal to them. Sometimes, eclecticism is useful while many a times it may confuse the path laid before therapy one needs to plan and pave a session by session model even when using eclectic approaches in psychotherapy.[9],[10]

Challenge 6 – Documentation and maintaining notes of therapy sessions

Psychotherapy is a treatment where everything happens behind the closed door of a therapy room and a prescription is not offered unlike when medicine is prescribed. It is vital that psychiatrists maintain detailed notes of therapy sessions because this serves as a record to demonstrate what was achieved session by session and also serve as documentation in case of any legal issues or treatment notes that can be presented when time arises. Time constraints may lead to a lack of documentation of sessions, and when patients may come back after some months and demand a record of what treatment happened, it may be difficult for the busy psychiatrist to remember what transpired in psychotherapy sessions that may have happened some months or years back. It is thus vital that psychotherapy documentation be maintained and this is indeed another challenge for office-based psychotherapy.[11]

Another emerging challenge is the scenario when patients with severe mental illness and serious psychiatric disturbances demand only psychotherapy as a treatment when actually they need medication combined with therapy to help them best. This is even more important now so with the advance directive concept enabling patients to determine their treatment with the advent of the new mental health-care bill. Patients who demand only psychotherapy as a treatment may be regular with therapy sessions and actively participate in the same but may not show same response to therapy as they would have shown if therapy was combined with medical treatment. While therapy may help them deal with many emotional issues, some symptoms such as delusions and hallucinations, nonsuicidal self-injury, and lack of motivation and depressed mood may not be amenable to therapy alone. They would need the help of psychopharmacology to help them overcome certain symptoms. Refusing psychopharmacology as an option and seeking only psychotherapy as treatment further delays recover. Insistence on medical therapy may cause the patient to seek help elsewhere and lose faith in the psychiatrist. Thus, managing patients who only demand psychotherapy as a treatment is another challenge for psychiatrists who provide psychotherapy.[12],[13]

Challenge 8 – Dealing with transference and countertransference

Psychotherapy involves two individuals, i.e., the therapist and patient coming together in a therapy setting and there is often an exchange of information between them. Both patient and therapist observe one another during the process of therapy. While the therapist may try to maintain neutrality and accurate empathy, there may be instances when transference develops with a resultant positive countertransference in wake of emotional exchanges and certain therapist disclosures. Psychiatrists are well aware of transference and countertransference as concepts, but negotiating the same is an art that is seldom taught in postgraduate training. Thus, a novice therapist may find himself or herself at wits end when transference or countertransference develops and may be pulled further into this web of emotional attachment. This is detrimental to further therapy that may ensue and hence dealing with the same is a challenge in office-based psychotherapy that one must be ready and trained for. Sometimes, transference may be so severe that it may warrant the need for a change in therapist and the psychiatrist must be wise enough to do this even if it means losing a patient.[14],[15]

Challenge 9 – How to choose the right patient for psychotherapy

It is always a challenge to choose the right patient for psychotherapy. This stems from the premise that while patients may agree for psychotherapy as a treatment, they may not always have the right mindset for it. An ability to accept one's mistakes and to speak about them as well as have the inclination to change along with a certain psychological mindedness and insight into one's illness are prerequisites for favorable outcomes in psychotherapy. Many a times choosing the wrong patients affects the outcome of psychotherapy rather than many therapist and therapy variables. Training in choosing patients for psychotherapy is scarce, and hence, a mistake made in choice of patient can be detrimental to confidence of both the patient and therapist. It is vital in office-based private practice psychotherapy that we choose the right patient to avoid a loss of human resource and also enhance outcome of the treatment.[16]

Challenge 10 – The emergence of online psychotherapy

Advances in communication technology have facilitated the development of online psychotherapy. This form of psychotherapy would provide the developing world with better access to professional mental health-care services. Patients from any part of the country would gain access to therapists from all over the country. At the same time, it is prudent to carefully consider the various ethical, legal, and regulatory issues involved in online psychotherapy. No formal training is available in online psychotherapy. Guidelines for conduction of sessions, guidelines for storage of online session data, and online platforms that allow therapy in a safe environment are conspicuous by their absence. Many authors and organizations have expressed their opinions on the subject, but no consensus has evolved in the Indian scenario. Psychiatrist venturing into the realm of online psychotherapy needs to be aware of the moral and ethical dilemmas that surround this form of treatment and must be equipped to brace the challenges that lie ahead. It is preferable to meet a patient in person as vital personal observation data may be missed in a pure online environment. Thus, patients demanding and referred for pure online psychotherapy are a challenge for office-based therapy.[17]

Challenge 11 – The challenge of psychotherapy with adolescents

Adolescents are a special population group for psychotherapy in private settings. They are often accompanied by parents and caregivers who pay for the therapy rendered. It is commonplace for parents demanding to know what the adolescent has spoken to the therapist. It is vital that issues such as confidentiality and what amount of disclosure would be done to parents be clarified to parents and the adolescent at the start of therapy. Adolescent patients in therapy may be untruthful and manipulative, and the therapist may have to confirm facts from parents before deciding on what to totally believe in. Important facts about the adolescent's life like his smoking or drinking habits along with sexual exposure and unsafe sexual practices may be conveyed to therapist and confidentiality about the same may be demanded. The same may hold true for suicidal and homicidal feelings. It is prudent that the therapist discusses these issues in joint meetings with the parents and trust in both the adolescent and his parents is thereby fortified and reciprocated throughout therapy. Thus, psychotherapy with adolescents is another challenge in school and office settings.[18]

Challenge 12 – The termination of psychotherapy

One of the least thought out areas in psychotherapy is the termination of psychotherapy. Psychiatrists ending psychotherapy with their patients face the challenge of how to end well and continue to maintain follow-up with their patients. Patients must be made ready for the termination and mentally prepared for the same. This goes a long way to bring in a successful culmination of all the efforts put into psychotherapy. Planning out future follow-up and maintenance sessions are also essential at the time of termination along with both the patient and therapist being mentally ready about the end of therapy. A family session before therapy ends may help the patient garner further social support which during therapy was being provided by the therapist.[19],[20]

Conclusions

This paper has tried to elucidate the various challenges one may encounter while starting and maintaining an office psychotherapy practice in private settings. It is essential to understand that challenges have been individually dealt with in a superficial manner while we admit that each of them has varied facets individually and beyond the scope of this paper meriting a separate review paper each. The paper provides an insight from a private practice perspective and hopes not to deter private psychiatrists from having a psychotherapy practice.